الاستمارة 8621-A
Instructions for Form 8621-A, Return by a Shareholder Making Certain Late Elections to End Treatment as a Passive Foreign Investment Company
Rev. December 2018
النماذج ذات الصلة
- الاستمارة 8621-A - Return by a Shareholder Making Certain Late Elections to End Treatment as a Passive Foreign Investment Company
Department of the Treasury
Internal Revenue Service
Instructions for Form 8621-A
(Rev. December 2018)
(Use with the December 2013 revision of Form 8621-A.)
Return by a Shareholder Making Certain Late Elections To End Treatment as a
Passive Foreign Investment Company
Section references are to the Internal Revenue Code
unless otherwise noted.
election is filed with the IRS. See the
Complete Part IV of the form along with
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any required attachments requested on any
of the lines in Part IV.
Sign and date the form in the spaces
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Future Developments
How To Complete Form
8621-A
provided at the bottom of page 2 of the form.
For the latest information about
developments related to Form 8621-A and
its instructions, such as legislation enacted
after they were published, go to IRS.gov/
If the election year is a closed tax year, file
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The shareholder makes the applicable
election in Part I of the form. The shareholder
then provides basic information about the
election in Part II or Part III of the form and
computes the tax and interest due in Part IV
of the form.
the closing agreement on page 3 of the form
in duplicate. Both copies must contain
Agreement, later, for details.
Complete the balance sheet on page 4 of
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the form, if applicable (that is, if required by
line 4 or line 8 of the form).
General Instructions
closed tax year, the taxpayer must enter into
a closing agreement (page 3 of the form) to
agree to eliminate any prejudice to the
interests of the U.S. government as a
Keep a copy of the form for your records.
Make your check or money order payable
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Purpose of Form
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A U.S. person that is a direct or indirect
shareholder of a former Passive Foreign
Investment Company (PFIC) or a Section
1297(e) PFIC is treated for tax purposes as
holding stock in a PFIC and therefore
to “United States Treasury.” Include your
identifying number and “Form 8621-A” on
your payment.
consequence of the taxpayer's inability to file
an amended return for the election year.
If Form 8621-A doesn't include full
payment of the amount shown on
continues to be subject to taxation under
section 1291 unless the shareholder makes
a purging election under section 1298(b)(1).
!
The closing agreement must be filed
CAUTION
line 21 of the form, the form won’t be
in duplicate and both copies must
!
processed.
CAUTION
contain original signatures. See
Closing Agreement, later, for additional
A purging election under section 1298(b)
(1) is:
information.
Definitions
A deemed dividend election or a deemed
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Controlled Foreign Corporation
A separate Form 8621-A must be filed
for each PFIC for which a late purging
election is being made. See Chain of
ownership below for specific filing
requirements.
sale election made with respect to a former
PFIC under the rules of Regulations sections
1.1298-3(b) or 1.1298-3(c), or
(CFC)
See section 957(a) for definition.
A deemed dividend election or a deemed
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sale election made with respect to a Section
1297(e) PFIC under the rules of Regulations
sections 1.1297-3(b) or 1.1297-3(c).
CFC Overlap Rules
Chain of ownership. If the shareholder
owns one PFIC and through that PFIC owns
one or more other PFICs, the shareholder
must file a separate Form 8621-A for each
Section 1297(e) PFIC or former PFIC in the
chain for which a late purging election is
made. The shareholder files these Forms
8621-A together.
A 10% U.S. shareholder (defined in section
951(b)) of a CFC that is also a PFIC that
includes in income its pro rata share of
subpart F income of the CFC generally won’t
be subject to the PFIC provisions for the
same stock during the qualified portion of the
shareholder's holding period of the stock in
the PFIC. This exception doesn’t apply to
option holders. For more information, see
section 1297(d).
A timely filed purging election is made on
Form 8621.
Form 8621-A is used only to make a late
purging election under section 1298(b)(1). A
late purging election is a purging election
under section 1298(b)(1) that is made:
In the case of a shareholder of a former
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Where To File
PFIC, after 3 years from the due date, as
extended, of the tax return for the tax year
that includes the termination date, or
File Form 8621-A with:
Qualified portion of holding period. For
purposes of section 1297(d), the qualified
portion of the shareholder's holding period in
a corporation is the portion of the
Internal Revenue Service
Deposit Team, M/S 6059
Attn: Specials Desk
In the case of a shareholder of a section
•
1297(e) PFIC, after 3 years from the due
date, as extended, of the tax return for the
tax year that includes the CFC qualification
date.
Ogden, UT 84201
shareholder's holding period:
That is after December 31, 1997, and
During which the shareholder is a U.S.
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Filing Checksheet
shareholder under section 951(b) and the
corporation is a CFC.
See Regulations sections 1.1298-3(e) or
1.1297-3(e) for more details.
Be sure to:
Check the applicable box in Part I of the
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CFC qualification date. The CFC
Generally, the amount due with respect to
a late purging election is computed in the
same manner as if the purging election had
been timely filed. However, the taxpayer
must also pay interest on the amount due
determined for the period beginning on the
due date (without extensions) for the
form that corresponds to the election you are
making.
qualification date is the first day on which the
qualified portion of the shareholder's holding
period in the Section 1297(e) PFIC begins,
as determined under section 1297(d).
Complete the applicable lines in Part II or
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III of the form (along with any required
attachments requested on any of those lines)
as requested at the end of the election
description in Part I of the form.
Section 1297(e) PFIC. A foreign
corporation is a Section 1297(e) PFIC with
respect to a shareholder if:
taxpayer's income tax return for the election
year and ending on the date the late purging
Nov 26, 2018
Cat. No. 39731G
1. The foreign corporation qualifies as a
PFIC under section 1297(a) on the first day
on which the qualified portion of the
under section 1297(e)) held by the foreign
corporation during the tax year are assets
that produce passive income or that are held
for the production of passive income.
Part I. Elections
Election A. Late Deemed
Dividend Election With Respect
to a Former PFIC
shareholder's holding period in the foreign
corporation begins, as determined under
section 1297(d) (CFC overlap rule), and
Basis for measuring assets. When
determining PFIC status using the asset test,
a foreign corporation can use adjusted basis
if:
2. The stock of the foreign corporation
held by the shareholder is treated as stock of
a PFIC, under section 1298(b)(1), because,
at any time during the shareholder's holding
period of the stock, other than the qualified
portion, the corporation was a PFIC that
wasn’t a QEF.
This is a deemed dividend election under
section 1298(b)(1) that is made with respect
to a former PFIC after the time prescribed in
Regulations section 1.1298-3(c)(4) has
elapsed.
1. The corporation isn’t publicly traded
for the tax year and
2. The corporation (a) is a CFC or (b)
makes an election to use adjusted basis.
Publicly traded corporations must use fair
market value when determining PFIC status
using the asset test.
Who Can Make the Election
Election Year
This election can be made by a U.S. person
that is a shareholder of a foreign corporation
that is a former PFIC with respect to such
shareholder provided the foreign corporation
was a CFC during the last tax year as a
PFIC.
In the case of a former PFIC, the election
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year is the tax year of the electing
shareholder that includes the termination
date.
Look-thru rule. When determining if a
foreign corporation that owns at least 25%
(by value) of another corporation is a PFIC,
the foreign corporation is treated as if it held
a proportionate share of the assets and
received directly its proportionate share of
the income of the 25%-or-more owned
corporation.
In the case of a Section 1297(e) PFIC, the
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election year is the tax year of the electing
shareholder that includes the CFC
qualification date.
Effect of Election
A shareholder making this election is treated
as receiving a dividend of its pro rata share
of the post-1986 earnings and profits of the
former PFIC on the termination date. The
deemed dividend is taxed under section
1291 as an excess distribution, allocated
only to the days in the shareholder's holding
period during which the foreign corporation
qualified as a PFIC. For this purpose, the
shareholder's holding period ends on the
termination date. After the deemed dividend
election, the shareholder's stock isn’t treated
as stock in a PFIC unless the foreign
Former PFIC
A foreign corporation is a former PFIC with
respect to the shareholder if the corporation
satisfies neither the income test nor the asset
test (described under the definition of PFIC
below), but whose stock, held by that
shareholder, is treated as stock of a PFIC,
under section 1297(b)(1), because at any
time during the shareholder's holding period
of the stock the corporation was a PFIC
(under the income or asset test of section
1297(a) described below) that wasn’t a QEF,
and the shareholder hasn’t made a
Qualified Electing Fund (QEF)
A PFIC is a QEF if the U.S. person who is a
direct or indirect shareholder of the PFIC
elects (under section 1295) to treat the PFIC
as a QEF. See the instructions for Form 8621
for more information.
Shareholder
A shareholder is a U.S. person that is a
direct or indirect shareholder of the foreign
earlier, for definition.
corporation thereafter qualifies as a PFIC.
mark-to-market election with respect to the
PFIC.
Special Rules
Termination Date
Indirect Shareholder
For purposes of this election, the following
The termination date is the last day of the
last tax year of the foreign corporation during
which it qualified as a PFIC under section
1297(a).
Generally, a U.S. person is an indirect
shareholder of a Section 1297(e) PFIC or a
former PFIC if it is:
apply.
The basis of the shareholder's stock is
•
increased by the amount of the deemed
dividend. The manner in which the basis
adjustment is made depends on whether the
shareholder is a direct or indirect
shareholder. See Regulations section
1.1298-3(c)(6).
1. A direct or indirect owner of a
pass-through entity that is a direct or indirect
shareholder of a Section 1297(e) PFIC or a
former PFIC,
2. A shareholder of a PFIC that is a
shareholder of a Section 1297(e) PFIC, or a
former PFIC,
3. A 50%-or-more shareholder of a
foreign corporation that isn’t a PFIC and that
directly or indirectly owns stock of a Section
1297(e) PFIC or a former PFIC, or
4. A 50%-or-more shareholder of a
domestic corporation that owns a section
1291 fund.
Specific Instructions
Address and Identifying
For purposes of the PFIC rules only, the
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Number
shareholder's new holding period begins on
the day following the termination date.
Address. Include the suite, room, or other
unit number after the street address. If the
Post Office doesn’t deliver mail to the street
address and the shareholder has a P.O. box,
enter the box number instead.
The term “post-1986 earnings and profits”
•
means the undistributed earnings and profits
of the PFIC (as of the close of the tax year
that includes the termination date without
reduction for dividends distributed during the
tax year) accumulated in tax years beginning
after 1986 during which the CFC was a PFIC
and while the shareholder held the stock.
Identifying number. Individuals should
enter a social security number or taxpayer
identification number issued by the IRS.
Entities must enter an employer identification
number.
Passive Foreign Investment
Company (PFIC)
Line 3 Attachment
Shareholder Contact Information. If the
person to contact with respect to Form
8621-A is the taxpayer, enter “Same” in the
entry space for the name. If the person to
contact with respect to Form 8621-A is a
person other than the taxpayer, enter the
information requested and attach Form
2848.
A foreign corporation is a PFIC if it meets
either the income or asset test described
below.
The shareholder must attach a statement to
Form 8621-A that shows the calculation of its
pro rata share of the post-1986 earnings and
profits of the former PFIC that is treated as
distributed to the shareholder on the
1. Income test. 75% or more of the
corporation's gross income for its tax year is
passive income (as defined in section
1297(b)).
termination date. The post-1986 earnings
and profits can be reduced (but not below
zero) by the amount that the shareholder
satisfactorily shows was previously included
in its income or in the income of another U.S.
2. Asset test. At least 50% of the
average percentage of assets (determined
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Instructions for Form 8621-A (Rev. 12-2018)
person. The shareholder shows this by
including in the statement mentioned above
the following information:
How To Make the Election
To make this election, check box B in Part I
and complete Part II, lines 1, 2, and 4, and
Part IV.
Line 7 Attachment
The shareholder must attach a statement to
Form 8621-A that shows the calculation of its
pro rata share of the post-1986 earnings and
profits of the Section 1297(e) PFIC that is
treated as distributed to the shareholder on
the CFC qualification date. The post-1986
earnings and profits can be reduced (but not
below zero) by the amount that the
The name, address, and identifying
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number of the U.S. person and the amount
that was previously included in income;
For more information regarding making
Election B, see Regulations section
1.1298-3(b) and Regulations section
1.1298-3(e).
The tax year in which the amount was
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previously included in income;
The provision of law under which the
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amount was previously included in income;
shareholder satisfactorily shows was
previously included in its income or in the
income of another U.S. person. The
shareholder shows this by including in the
statement mentioned above the following
information:
A description of the transaction in which
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Election C. Late Deemed
Dividend Election With Respect
to a Section 1297(e) PFIC
the shareholder acquired the stock of the
former PFIC from the other U.S. person; and
The provision of law under which the
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shareholder's holding period includes the
holding period of the other U.S. person.
This is a deemed dividend election under
section 1298(b)(1) that is made by a
shareholder (defined earlier) with respect to
a Section 1297(e) PFIC that is also a CFC
after the time prescribed in Regulations
section 1.1297-3(c)(4) has elapsed.
The name, address, and identifying
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number of the U.S. person and the amount
that was previously included in income;
How To Make the Election
To make this election, check box A in Part I
and complete Part II, lines 1, 2, and 3, and
Part IV.
The tax year in which the amount was
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previously included in income;
A description of the transaction in which
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the shareholder acquired the stock of the
Section 1297(e) PFIC from the other U.S.
person; and
Who Can Make the Election
For more information on making Election
A, see Regulations section 1.1298-3(c) and
Regulations section 1.1298-3(e).
The election can be made by a shareholder
of a foreign corporation that is a Section
1297(e) PFIC with respect to that
shareholder.
The provision of law under which the
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shareholder's holding period includes the
holding period of the other U.S. person.
Election B. Late Deemed Sale
Election With Respect to a
Former PFIC
Effect of Election
How To Make the Election
To make this election, check box C in Part I
and complete Part III, lines 5, 6, and 7, and
Part IV.
A shareholder making this election is treated
as receiving a dividend of its pro rata share
of the post-1986 earnings and profits of the
Section 1297(e) PFIC on the CFC
This is a deemed sale election under section
1298(b)(1) that is made with respect to a
former PFIC after the time prescribed in
Regulations section 1.1298-3(b)(3) has
elapsed.
qualification date. The deemed dividend is
taxed under section 1291 as an excess
distribution, allocated only to the days in the
shareholder's holding period during which
the foreign corporation qualified as a PFIC.
For this purpose, the shareholder's holding
period ends on the day before the CFC
qualification date. After the deemed dividend
election, the shareholder's stock isn’t treated
as stock in a PFIC unless the qualified
portion of the shareholder's holding period
ends, and the foreign corporation thereafter
qualifies as a PFIC.
For more information on making Election
C, see Regulations sections 1.1297-3(c) and
(e).
Who Can Make the Election
Election D. Late Deemed Sale
Election With Respect to a
Section 1297(e) PFIC
This election can be made by a U.S. person
that is a shareholder of a former PFIC.
Effect of Election
This is a deemed sale election under section
1298(b)(1) that is made with respect to a
Section 1297(e) PFIC after the time
prescribed in Regulations section
1.1297-3(b)(3) has elapsed.
A shareholder making this election is
deemed to have sold the former PFIC stock
on the termination date for its fair market
value. The gain from the deemed sale is
taxed under section 1291 as an excess
distribution received on the termination date.
After the deemed sale election, the
Special Rules
Who Can Make the Election
For the purpose of this election, the following
This election can be made by a U.S. person
that is a shareholder of a foreign corporation
that is a section 1297(e) PFIC with respect to
such shareholder.
shareholder's stock isn’t treated as stock in a
PFIC unless the foreign corporation
thereafter qualifies as a PFIC.
apply:
The basis of the shareholder's stock is
•
increased by the amount of the deemed
dividend. The manner in which the basis
adjustment is made depends on whether the
shareholder is a direct or indirect
shareholder. See Regulations section
1.1297-3(c)(6).
Special Rules
Effect of Election
For purposes of this election, the following
A shareholder making this election is
deemed to have sold the Section 1297(e)
PFIC stock on the CFC qualification date for
its fair market value. The gain from the
deemed sale is taxed under section 1291 as
an excess distribution received on the CFC
qualification date. After the deemed sale
election, the shareholder's stock isn’t treated
as stock in a PFIC unless the qualified
portion of the shareholder's holding period
ends, and the foreign corporation thereafter
qualifies as a PFIC.
apply.
The basis of the shareholder's stock is
•
For purposes of the PFIC rules only, the
•
increased by the gain recognized on the
deemed sale. The manner in which the basis
adjustment is made depends on whether the
shareholder is a direct or indirect
shareholder. See Regulations section
1.1298-3(b)(5).
shareholder's new holding period begins on
the CFC qualification date.
The term “post-1986 earnings and profits”
•
means the undistributed earnings and profits
of the PFIC (as of the day before the CFC
qualification date) accumulated in tax years
beginning after 1986 during which the CFC
was a PFIC and while the shareholder held
the stock.
For purposes of the PFIC rules only, the
•
shareholder's new holding period of the
stock begins on the day following the
termination date.
The election can be made for stock on
•
which the shareholder will realize a loss, but
that loss cannot be recognized. In addition,
there is no basis adjustment for a loss.
Instructions for Form 8621-A (Rev. 12-2018)
-3-
allocated to the election year. Enter the sum
on line 10.
(without regard to extensions) of your
income tax return for the tax year to which an
increase in tax is attributable and ending with
the due date (without regard to extensions)
of your income tax return for the election
year.
Special Rules
For purposes of this election, the following
With respect to the amounts allocated to
•
apply.
each tax year in your holding period other
than the election year and the pre-PFIC
The basis of the shareholder's stock is
•
increased by the gain recognized on the
deemed sale. The manner in which the basis
adjustment is made depends on whether the
shareholder is a direct or indirect
shareholder. See Regulations section
1.1297-3(b)(5).
Lines 18 and 19
Lines 11 and 12
The line 18 subtotal represents all amounts
due as of the due date (without regard to
extensions) of the shareholder's income tax
return for the election year. The shareholder
making the late deemed dividend or late
deemed sale election must pay additional
interest on the amount on line 18 from the
due date (without regard to extensions) of its
income tax return for the election year up to
and including the date the Form 8621-A and
payment are filed with the IRS. Include this
interest amount on line 19.
The shareholder's income tax liability is
generally the amount shown on the “total tax”
line of the return.
For purposes of the PFIC rules only, the
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shareholder's new holding period begins on
the CFC qualification date.
Line 14
Determine the increase in tax for each tax
year in your holding period other than the
election year and pre-PFIC years (that is, for
each PFIC year). An increase in tax is
determined for each PFIC year by multiplying
the part of the distribution or disposition
earlier) by the highest rate of tax under
section 1 or section 11, whichever applies, in
effect for that tax year. Add the increases in
tax computed for all PFIC years. Enter the
aggregate increases in tax (before credits)
on line 14.
The election can be made for stock on
•
which the shareholder will realize a loss, but
that loss cannot be recognized. In addition,
there is no basis adjustment for a loss.
How To Make the Election
To make this election, check box D in Part I
and complete Part III, lines 5, 6, and 8, and
Part IV.
Closing Agreement
If the election year is a closed tax year, file
the closing agreement on page 3 of the form
in duplicate. Both copies must contain
original signatures. Photocopies of
For more information on making Election
D, see Regulations sections 1.1297-3(b) and
(e).
signatures aren’t acceptable. The closing
agreement on page 3 of the actual form you
file is the IRS copy. The photocopy of the
closing agreement that you attach to the
4-page form is the taxpayer copy. Write
“Taxpayer Copy” in the upper margin of this
copy. File the taxpayer copy as the first
attachment after the 4-page form. The
taxpayer copy will be returned to you after an
authorized IRS official has signed it.
Line 15
To determine the foreign tax credit, the
shareholder of a section 1291 fund
Part IV. Computation of
Tax and Interest Due
determines the total creditable foreign taxes
attributable to the distribution. The total
creditable foreign taxes with respect to any
distribution are the withholding taxes
imposed on the distribution and, in the case
of a foreign corporation year beginning
before January 1, 2018, for 10% or greater
corporate shareholders, any taxes deemed
paid under section 902. The taxes must be
creditable under general foreign tax credit
principles and the shareholder must choose
to claim the foreign tax credit for the current
tax year.
Line 9a
Enter the amount treated as an excess
distribution under the deemed dividend or
deemed sale election. This amount is:
Identifying number. Individuals should
enter a social security number or taxpayer
identification number issued by the IRS.
Entities must enter an employer identification
number.
In the case of a deemed dividend election
•
for a former PFIC, the amount on line 3 of
Part II.
In the case of a deemed sale election for a
•
former PFIC, the amount on line 4 of Part II.
In the case of a deemed dividend election
•
for a Section 1297(e) PFIC, the amount on
line 7 of Part III.
Balance Sheet
The excess distribution taxes (the
creditable foreign taxes attributable to an
excess distribution) are allocated in the
same manner as the excess distribution is
allocated. See the instructions for Lines 9b
allocated to pre-PFIC tax years and the
election year are taken into account for the
election year under the general rules of the
foreign tax credit.
If the shareholder is making a late deemed
sale election with respect to a former PFIC or
a Section 1297(e) PFIC (Election B or D), the
shareholder is required to complete the
balance sheet on page 4 of Form 8621-A.
In the case of a deemed sale election for a
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Section 1297(e) PFIC, the amount on line 8
of Part III.
Lines 9b and 10
Determine the allocation of the excess
Note. If the PFIC uses the U.S. dollar
approximate separate transactions method
of accounting (DASTM), the balance sheet
should be prepared and translated into U.S.
dollars according to Regulations section
1.985-3(d), rather than U.S. GAAP.
distribution to all applicable tax years on a
separate sheet and attach it to Form 8621-A.
Divide the amount on line 9a by the number
of days in your holding period. The holding
period of the stock is treated as ending on:
The excess distribution taxes allocated to
a PFIC year only reduce the increase in tax
figured for that tax year (but not below zero).
No carryover of any unused excess
The termination date, in the case of a
•
deemed sale or deemed dividend election
for a former PFIC;
Line 11
distribution taxes is allowed.
The CFC qualification date, in the case of
•
You must attach to Form 8621-A a written
narrative for each intangible asset describing
how the asset valuation was determined.
This narrative must include all pertinent
valuation information including whether the
valuation was done by a third party. If the
valuation was done by a third party, include
the name and business address of that third
party in the narrative.
When you dispose of PFIC stock, the
above foreign tax credit rules apply only to
the part of the gain that, without regard to
section 1291, would be treated under section
1248 as a dividend.
a deemed sale election for a Section 1297(e)
PFIC; and
The day before the CFC qualification
•
date, in the case of a deemed dividend
election for a Section 1297(e) PFIC.
Line 16
Determine the amount allocable to each
tax year in your holding period by adding the
amounts allocated to the days in each such
tax year. Then:
This amount is the aggregate increases in
taxes on the excess distribution within the
meaning of section 1291(c)(2).
Disclosure, Privacy Act, and Paperwork
Reduction Act Notice. We ask for the
information on this form to carry out the
Internal Revenue laws of the United States.
Add the amounts allocated to the tax
•
Line 17
years before the foreign corporation became
a PFIC (pre-PFIC years) and amounts
Compute the interest on each net increase in
tax for the period beginning on the due date
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Instructions for Form 8621-A (Rev. 12-2018)
Sections 6001, 6011, 6012(a), 6103, and
6109, and their regulations, require you to
provide this information. We need this
information to ensure that you are complying
with the Internal Revenue laws and to allow
us to figure and determine the right amount
of tax.
for civil and criminal litigation. We may also
disclose this information to cities, states, the
District of Columbia, and U.S.
estimated burden for all other taxpayers who
file this form is shown below.
commonwealths and possessions for use in
administering their tax laws, to federal and
state agencies to enforce federal nontax
criminal laws, or to federal law enforcement
and intelligence agencies to combat
terrorism.
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information requested on a form that is
subject to the Paperwork Reduction Act
unless the form displays a valid OMB control
number. Books or records relating to a form
or its instructions must be retained as long as
their contents may become material in the
administration of any Internal Revenue law.
If you have comments concerning the
accuracy of these time estimates or
suggestions for making this form simpler, we
would be happy to hear from you. You can
send us comments from IRS.gov/
prosecution. Section 6109 requires return
preparers to provide their identifying
numbers on the return.
Generally, tax returns and return
The time needed to complete and file this
form will vary depending on individual
circumstances. The estimated burden for
individual and business taxpayers filing this
form is approved under OMB control
FormsComments. You can write to the
Internal Revenue Service, Tax Forms and
Publications, 1111 Constitution Ave. NW,
IR-6526, Washington, DC 20224. Don’t send
the tax form to this address. Instead, see
Where To File, earlier.
information are confidential, as required by
section 6103. However, section 6103 allows
or requires the Internal Revenue Service to
disclose or give the information shown on
your tax return to others as described in the
Code. For example, we may disclose your
tax information to the Department of Justice
numbers 1545-0074 and 1545-0123. The
Instructions for Form 8621-A (Rev. 12-2018)
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